Project Summary Birth-related outcomes, specifically cesarean section rates, gestational age, and birth weight, indicate maternal and child health, and have life-long impacts on the health of children. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and linkage to social and health services. The majority of HV programs target first-time mothers, in part due to the assumption that later children will also benefit. HV goals and activities in the second preconception, and possibly prenatal, period have the potential to improve second child birth outcomes. However, there are sparse data on subsequent birth outcomes; programs that engage mothers during pregnancy focus on the first child and other programs engage mothers around the time of the first child's birth and do not focus on any birth outcomes. We propose to use data from a statewide HV program (Nurturing Families Network [NFN]) and birth certificates to examine second births to home visited mothers. NFN enrolls most mothers shortly after the birth of their first child and uses the evidence-based Parent as Teacher (PAT) curriculum. The availability of these NFN data provides an opportunity to examine a large community-based program without costly data collection. Birth certificate data will be used to create comparison groups for this observational study. Birth outcomes for the NFN second children (n=3,000 children) will be compared to: (a) their older siblings (the child whose birth led to enrollment in NFN; n=3,000), (b) children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n=650), and (c) a propensity-score-matched group of non-NFN children (created using the likelihood to enroll in the program based on maternal health, individual demographics, and neighborhood characteristics; n=6,000). We will examine birth spacing, receipt of prenatal care, cesarean section rate, gestational age, and birth weight for second children of NFN families, compared to the groups described above. We will conduct sub-analyses by race and by age (<20 vs. ?20 years) to examine differences for mothers in vulnerable groups. We will also examine program engagement (dropout and missed visits) for those enrolled in NFN and associations between program engagement and birth outcomes. This project will generate evidence on the potential long-term benefits of a statewide program to the second child of home-visited mothers. This evidence is important to support continued funding of these programs and to determine if the assumption that later children will gain benefits justifies the focus on first-time mothers. Understanding the impact of program engagement on later outcomes will help the program prioritize retention efforts. This project will strengthen the research environment of the Yale School of Nursing by providing students an opportunity to engage in secondary data analysis and by building expertise in the school for conducting research using large administrative datasets and utilizing advanced statistical methods.